Transcript ABDOMINAL COMPARTMENT SYNDROME

ABDOMINAL
COMPARTMENT SYNDROME
CVICU Rounds
Dr. Alan Sobey
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ABDOMINAL
COMPARTMENT SYNDROME
• GI complications affect up to 3% of cardiac
surgery cases.
• Depending on the complication rate the
mortality rates can be as high as 64%
• Known to occur with massive resuscitation,
liver transplantation, elective surgical
procedures, “septic abdomens” and with
severe burns
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Abdominal Compartment
Syndrome
• OUTLINE
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Definition
History
Measurements
Significance
Summary
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Abdominal Compartment
Syndrome
• Definition: Elevated intra-abdominal
pressure (IAP)
– Sustained increase in the intra-abdominal
pressure over normal: > 12mmHg
– Multiple etiologies
– NB: not the same as ACS
– ACS is a late consequence of increased IAP
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Abdominal Compartment
Syndrome
• Definition: Compartment Syndrome
– Compartment Syndrome:
• An increase in pressure within an enclosed space or
cavity that causes physiologic dysfunction of its
contents.
• Ex: extremities following fracture or
revascularization of a limb
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Abdominal Compartment
Syndrome
• Definition: ACS
– The adverse physiologic effects due to
increased intra-abdominal pressure.
– Prolonged and unrelieved pressure may lead to
respiratory compromise, renal impairment,
cardiac failure, shock and death.
– Generally it is measured from the intracystic
pressure (bladder pressure).
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Abdominal Compartment
Syndrome
• HISTORY:
– Fietsam et al (1989) first presented the notion
of the abdominal compartment syndrome
(ACS) to describe the collective effects of
increased intra-abdominal pressure (IAP) on the
body.
– Their description was in the setting of ruptured
abdominal aortic aneurysms.
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Abdominal Compartment
Syndrome
• HISTORY:
– Trauma literature now a major source of
information.
– In general, the trauma literature has recognized
that end organ dysfunction occurs in the
presence of a grossly distended and tense
abdomen.
– Open abdomen concept
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Abdominal Compartment
Syndrome
• PATHOPHYSIOLOGY:
– Usual intra-abdominal pressure is assumed to
be near atmospheric
– Sugerman et al: increased with increasing
abdominal girth
– Kron et al: 3 – 15 mmHg (5-7)
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Abdominal Compartment
Syndrome
• PATHOPHYSIOLOGY:
– As the volume in the abdomen rises so does the
pressure:
• the increase in pressure is in proportion to the
abdominal wall compliance
• Increase in pressure is in proportion to the increase
in the intra-abdominal pressure.
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Abdominal Compartment
Syndrome
• PATHOPHYSIOLOGY:
– Corresponding decrease in hepatic / splanchnic
/ renal perfusion – presumably due to
compression of these vascular beds.
– 20% of the rise in the IAP is transmitted to the
thoracic cavity:
• Increase in juxtacardiac pressure.
• Impaired ventricular filling.
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Abdominal Compartment
Syndrome
• PATHOPHYSIOLOGY:
• Increased left ventricular afterload (with decreased
CO and increased PCWP)
• Increased work of breathing due to decreased
diaphragmatic excursion and impairment of chest
wall movement.
• Increased intracranial pressure (significant in the
head injured trauma patient)
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Abdominal Compartment
Syndrome
• CONSEQUENCES:
SUMMARY
• Decreased cardiac output
• Increased work of
• Elevated RAP and PCWP
breathing
• Reduced hepatic perfusion • Elevated airway pressures
• Lactic acidosis
during mechanical
• Splanchnic hypoperfusion
ventilation
• Raised ICP
• Abnormal V/Q matching
• Peripheral edema with
with hypoxemia
tendency to thrombosis
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Abdominal Compartment
Syndrome
• ETIOLOGY
• Intra-peritoneal or
retroperitoneal
hemorrhage
• Ascites
• Bowel obstruction
• Post-op edema
• Pneumoperitoneum
• Laparoscopy
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Acidosis
Hyperthermia transfusion
Coagulopathy Sepsis: intra
or extra abd
Bacteremia
pancreatitis
Liver
dysfunction
Mechanical
ventilation
Pneumonia
Abdominal
Massive
surgery (DCL) resuscitation
Gastric or
colon dist’n
Hemoperitoneum
Burns and
trauma
BMI
Abdominal
tumors
Prone
ventilation
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Abdominal Compartment
Syndrome
• INDEX OF SUSPICION: Setting
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Ascites
Bowel distention: mech obstruction/ileus
Bowel edema: resuscitation or ischaemia
Retroperitoneal hematoma
Hemoperitoneum
Coagulopathy
Trauma
Abdominal packing after damage control surgery
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Abdominal Compartment
Syndrome
• DIAGNOSIS: Index of suspicion
– When any signs of intra-abdominal
hypertension are present:
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Abdominal distention
Refractory oliguria
Hypercarbia
Refractory hypoxemia
Increasing PIPs
Refractory hypotension
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Abdominal Compartment
Syndrome
• DIAGNOSIS: Measuring the pressure
– Insert a Foley catheter and clamp the tube distal to the
sample port
– Instill 5-1000mL of saline into the bladder so as to
leave a continuous column of fluid from the bladder to
the sample port on the Foley
– Insert a 18g catheter into the sample port and connect to
a CVP transducer
– Level the transducer at the symphysis pubis
Fusco et al J Trauma 2001
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Abdominal Compartment
Syndrome
• Measurement: WSACS
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Cmpletely supine
Relaxed abdominal wall
mid-axillary line
25 mL saline into the bladder
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Abdominal Compartment
Syndrome
• DIAGNOSIS;
– Most papers suggest several measurements
during a 24 hr period: every 4 hrs
– Repeat measurements are indicated by the
clinical appearance of the abdomen and on the
clinical situation (index of suspicion)
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Abdominal Compartment
Syndrome
• INTERPRETATION: NORMAL IAP
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3-15 mmHg
Obesity: higher (8 vs. 5 mmHg)
Age: no definite trend
Surgery: no definite trend
Comorbidities: trend to higher IAP with more
concurrent illnesses
Sanchez et al Am Surg Mar 2001
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Abdominal Compartment
Syndrome
• INTERPRETATION:
– As the pressure rises over 20cm water there will be
some evidence of hypoperfusion
– Most will accept surgical decompression if the intraabdominal pressure is over 35 cm.
– More recent authors are advocating surgical
decompression for IAP of 20-25 mmHg (Cheatham et
al)
– WSACS: 20mmHg for treatment
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Abdominal Compartment
Syndrome
• INTERPRETATION: evidence
– Decreased ACS with earlier decompression
– Decreased mortality with earlier
decompression: ?
– More pronounced benefit with increasing age
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Abdominal Compartment
Syndrome
• Management:
– Medical:
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Maintain APP (>60mmHg)
Sedation / Analgesia
NMB
Supine positioning
NG / Colonic decompression
Fluid resuscitation
diuretics
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Abdominal Compartment
Syndrome
• Surgical:
– Percutaneous tube drainage
– Abdominal decompression (DCL)
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Abdominal Compartment
Syndrome
• TREATMENT: SURGICAL DECOMPRESSION /
DAMAGE CONTROL LAPAROTOMY
– Surgical decompression involves opening the
abdominal wound and packing the wound open or
closing it with a plastic dressing (Bogata Bag)
– Delayed closure can be done once the edema / bleeding
has resolved
– Ascites can be drained percutaneously
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Abdominal Compartment
Syndrome
• DAMAGE CONTOL LAPAROTOMY:
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Stone et al (1982)
Penetrating injuries to the abdomen
Avoid hypothermia / acidosis / coagulopathy
Involves:
• Rapid control of bleeding and contamination
• Abdominal packing instead of involved procedures
• Skin closure only or plastic tent closure (3 L
peritoneal / CVVHDF bag)
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Abdominal Compartment
Syndrome
• DAMAGE CONTROL LAPAROTOMY
– Offner et al (Arch Surg)
• Denver Colo
• Penetrating and blunt traumas
• ACS:
– Long hospital stay
– Increased multisystem organ failure
– Increased ARDS
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Abdominal Compartment
Syndrome
• Offner et al
– Technique of closure and ARDS/MSOF and ACS
ACS
MSOF/ARDS
Primary
closure
80%
90%
Skin
24%
36%
Bogota bag
18%
47%
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Abdominal Compartment
Syndrome
• SUMMARY:
– IAP – measureable / preventable / treatable
– ACS – end organ dysfunction from untreated or
undertreated elevated IAP
– Measurement: simple technique with an 18 g
needle through the Foley port and a CVP
transducer
– Damage control – the standard for avoiding or
treating elevated IAP or ACS
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Abdominal Compartment
Syndrome
• Deompressive laparotomy: Effects
• Most studies show a significant decrease in the
IAP
• IAH persists in the majority of patients (De Waele
et al)
• MR remained high at 35%
• Overall benefit for oxygenation (PaO2/FiO2) and
increased urine output
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Abdominal Compartment
Syndrome
• Decompressive Laparotomy: Effects
• The wound:
– Messy
– Open - risks for colonization or secondary
infection
– Delayed closure: how?
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Abdominal Compartment
Syndrome
• Decreased renal output:
– Harman et al
– Dogs
– Increased the intra-abdominal pressure to
40mmHg leading to decreased urine output and
cardiac output
– Resuscitated the dogs to normal CO yet the
renal function remained impaired until the
abdomen was decompressed
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Abdominal Compartment
Syndrome
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INTRACRANIAL PRESSURE:
– Increased
1. Due to increased intrathoracic pressure from
the elevated diaphragms
2. Due to decreased cardiac output
– Thus, increases cerebral hypoperfusion and
worsens brain injury
Citero et al CCM
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Abdominal Compartment
Syndrome
• Definitions:
– IAH: intra-abdominal hypertension
• Sustained increase in IAP of 12 mmHg or more over
3 recordings separated by 4hrs each
– ACS: abdominal compartment syndrome
• Sustained increase in IAP of 20mmHg or more
• Single or multiple organ system failure that was not
previously present
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Abdominal Compartment
Syndrome
• Classification:
– Primary:
• Due to injury or disease in the abdomen or pelvis
• Frequently requires surgery or radiological
treatment
• Ex: trauma or the septic abdomen
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Abdominal Compartment
Syndrome
– Secondary:
• ACS due to conditions arising outside of the
abdomen
• Associated with severe capillary leak requiring
resuscitation
• Ex: sepsis, burns, retroperitoneal hematoma
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Abdominal Compartment
Syndrome
• Recurrent ACS:
– Occurs following either prophylactic
decompression or therapeutic surgical
decompression of either primary or secondary
ACS
– Ex: temporary closure device is too tight,
inadequate fascial opening, recurrs after the
fascia was closed.
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Abdominal Compartment
Syndrome
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APP: abdominal perfusion pressure
APP = MAP - IAP
“magic number”: 50-60
Corresponds to the perfusion gradient
across the intra-abdominal visera
• Evidence????
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Abdominal Compartment
Syndrome
• Diagnosis: Clinical Suspicion
• Presentation / Suspect with:
– Abdominal distention
– Oliguria
– Increased ventilatory support
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